Provider Demographics
NPI:1386125060
Name:JOHNSON, MELISSA E (LCPC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:E
Other - Last Name:NORVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2239 E COOK ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-1944
Mailing Address - Country:US
Mailing Address - Phone:217-788-2300
Mailing Address - Fax:217-788-2343
Practice Address - Street 1:2239 E COOK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-1944
Practice Address - Country:US
Practice Address - Phone:217-788-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011781101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional